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Gender Issues

Medical Students' Involvement in Outpatient Clinical Encounters: A Survey of Patients and Their Obstetricians–Gynecologists

Mavis, Brian, PhD; Vasilenko, Peter, PhD; Schnuth, Rae, PhD; Marshall, Joseph, MD; Jeffs, Madeline Colavito, PhD

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Abstract

Contact with patients remains a vital component in the education of medical students. The many contributions made by patients to the education of medical students have been outlined in a paper by Spencer and colleagues.1 Medical educators have been encouraged to implement experiences involving patient contact early in medical school curricula to enhance students' understanding of health care delivery from both the patient's and the community's perspective.2 Historically, such opportunities for medical students' involvement in patient care have been viewed positively both by physicians and medical students.1

Past studies have consistently documented patients' support for medical students' involvement in their care as well. Patients see their involvement with medical students altruistically, as a means of contributing to the education of future physicians; patients also have the opportunity to learn more about their own health.3–9 However, many of these studies also document that patients' enthusiasm for medical students' involvement decreases as the intimacy of the clinical encounter increases.

Issues surrounding patients' involvement in medical education have been particularly salient for training in obstetrics and gynecology (ob–gyn). The intimate nature of the history and physical examination during ob–gyn patient visits makes women less likely to consent to medical students' participation in their care.7 Generally, patient characteristics such as age, education, race, and socioeconomic status have been found to be unrelated to women's willingness to consent to medical students' involvement in their ob–gyn visits. Religious affiliation and parity have been identified as mediating factors in students' involvement in obstetrical care.7,10 Women's willingness to consent to medical students' participation in their care has been found to vary relative to the gender of the medical student.3,4,6,9–11 In most settings, a majority of women do not have a preference for the gender of the medical student involved in their care. For those women who do express a preference, they always favor female medical students. In practical terms, such patient preferences might translate into fewer educational opportunities for male students to participate in patient-based encounters focused on ob–gyn care.6 Many medical students and faculty misperceive that female patients prefer female providers,12 and there is on-going concern about discrimination against men and decreasing future career opportunities for men within obstetrics and gynecology.13

To our knowledge, there are few studies documenting physicians' perspectives on medical students' involvement in patients' ob–gyn care, particularly the extent to which their views are consistent with those of their patients. A number of research questions guided our study of women's experiences and perspectives on the involvement of medical students during ob–gyn office visits:

  • What is the extent of patients' prior exposure to medical students during their office visits?
  • Is there an association between prior experience with medical students and patients' likelihood of consenting to some degree of medical students' involvement in their care?
  • To what extent does a medical student's gender affect patients' decisions about the acceptability of medical students' involvement in their care?

In addition, including providers in this study permitted a comparison of providers' understanding of their patients' preferences related to medical students' involvement during clinical encounters.

Method

Setting

Michigan State University College of Human Medicine is a community-based medical school. Medical students complete the first two years of their education in East Lansing at the main university campus. Students are assigned to one of six community campuses for their clinical clerkships during the final two years of their education. These clinical campuses are located in six geographically diverse communities across the state.

Participant recruitment

In 1999–2000, we contacted 116 paid and volunteer faculty members in the Department of Obstetrics and Gynecology in each of the six community campuses to participate in the study and provided patient questionnaires to those faculty members who agreed to participate. We used a convenience sample for the patients: Over a one-week period, all women scheduled for a physician visit at the six participating practice sites were surveyed. Women scheduled for visits with nurse practitioners, ultrasound technicians, nurse midwives, physician assistants, or other health professionals were excluded from the study. Eligible patients were given a questionnaire when they checked in with the receptionist for their visit and asked to return the completed questionnaire to the receptionist before leaving the office.

The physicians also were asked to complete a questionnaire. Many of the questions were similar to those in the patients' questionnaire, but focused on physicians' opinions about how patients respond to the medical students involved in their care.

Questionnaire development

We developed the anonymous questionnaires to ascertain patients' preferences related to the involvement of medical students in their health care encounters. The first section of the questionnaires listed 11 medical student characteristics derived from a review of the literature since we could find no preexisting questionnaire that met our needs. Patients were asked to rate on a six-point scale the importance of each factor in their decisions whether to allow medical students to participate in care during their office visit (1 = not important, 6 = very important). For comparison purposes, the same 11 items were included in the physicians' questionnaire; they were asked to rate what they believed was the perceived importance that patients gave to each factor. The first part of the questionnaire also asked patients for their preferences related to interpersonal communications, clinical competence, and gender when selecting a physician. These findings have been previously reported.14

The second part of the patients' questionnaire focused on their experiences with medical students during their ob–gyn office visits, and the extent to which they would allow medical students to participate in their care. They also were asked about how knowledge of medical students' involvement might affect their choice of an ob–gyn. The physicians' questionnaire contained similar items regarding physicians' perceptions of patients' preferences. The final section of the questionnaire asked for patients' demographic information, including age, ethnicity, medical insurance coverage, marital status, and education level.

We pilot tested the questionnaire at a local clinic and made minor wording and formatting changes to improve clarity. This study was approved by the institutional review board at Michigan State University.

Data analysis

We analyzed the data using SPSS software Version 12.0 (SPSS Inc., Chicago, IL). Descriptive statistics were used to provide an overview of the physician and patient respondents. For comparing the responses of patients and physicians, we used chi-square analysis for categorical data and t tests for ratings and other continuous data. A factor analysis was used as a data reduction procedure and applied to the 11 items rated as important considerations by patients and physicians. The reduction of these items into a smaller number of linear combinations facilitated their use in the prediction model. The prediction model used multiple linear regression to test the importance of specific patient variables in predicting several indicators of patients' attitudes to medical students' involvement in their care.

Results

Respondents' characteristics

Patients.

A total of 1,059 patients returned the questionnaires. We do not know the response rate and representativeness of the respondents with regard to the total patient pool because of limited resources at the clinics to monitor patients' participation. Not all of the questionnaires were complete; the number of respondents for each question is provided in the text or tables.

Patients who responded ranged in age from 14 to 81 years with a mean of 33.6 years (median = 31). Eight-hundred thirty-two patients (84%) identified themselves as white, 687 (68%) were married, and 692 (69%) indicated some level of postsecondary education. Four hundred twenty-nine (44%) indicated some type of traditional insurance, while 324 (33%) indicated a managed care plan, and 200 (20%) a government-sponsored insurance.

Physicians.

Seventy-two physicians (62%) returned completed questionnaires; 47 were male (66%) and 59 identified themselves as white (84%). They ranged in age from 26 to 66 years (mean = 44.5; median = 44). Overall, 62 (89%) physicians participating in the survey were volunteer faculty with the medical school and 39 (57%) had held their faculty appointments for seven or more years. When asked to describe their practice arrangements, 35 (50%) said they were in a private group practice, 14 (20%) were in hospital-owned practice, 9 (13%) were solo, 4 (6%) were university affiliated, and 8 (11%) were other. Twenty-six (36%) practices did not include any female physicians. Physicians were asked to estimate separately the number of male and female medical students assigned to work with them over the past three years. They reported an average of 8.7 male students (median = 4) and 8.2 female students (median = 3).

Prior experience with medical students

The questionnaire asked patients if they had ever had medical students participate in their ob–gyn care. A similar questionnaire for physicians asked about their past experiences involving medical students in patient care. Fifty-four physicians (77%) reported experience with both male and female students in their practices; we found no differences related to the physician's gender. In contrast, 510 patients (51%) did not have any prior experience with medical students when seeking ob–gyn care (see Table 1). We found a significant difference between the experiences of physicians and patients (χ 2 = 243.72; df = 3; p < .001). In comparing patients with and without prior experience with medical students in their ob–gyn care, we found no differences with respect to any of the demographic characteristics included in the questionnaire.

Table 1
Table 1:
Patients' and Physicians' Past Experiences with Medical Students in Obstetrical and Gynecological Care, Six Clinical Campuses of Michigan State University College of Human Medicine, 1999–2000

Patients reporting prior experience with medical students (n = 488) were asked to rate their experience with the medical students. Using a five-point scale (1 = very positive, 5 = very negative), 131 patients (27%) indicated that the experience was positive and 168 (35%) that it was very positive. One hundred forty-four (30%) rated their experience as neutral, 23 patients (5%) rated the experience as somewhat negative, and 10 (2%) as very negative.

Patients' ratings of important considerations

We asked patients to rate the importance of various considerations in their decision whether to allow a medical student to participate in their care during their office visit. The physicians' questionnaire asked them to rate the importance of each consideration from the perspective of their patients. We found no differences when we compared the responses of male and female physicians. The general ordering of ratings were the same for patients and physicians; for most items, patients' ratings of importance were significantly higher than were physicians' ratings (see Table 2). The exceptions were “Student is male,” “Student is female,” and “Need to talk privately with my ob–gyn.” For these three items, the ratings of physicians were significantly greater than were the ratings given by patients. For one item, “I see my ob–gyn doctor once a year,” we found no difference in the ratings between patients and physicians.

Table 2
Table 2:
Patients' and Physicians' Mean Importance Ratings for Considerations Related to Medical Students' Participation in Obstetrical and Gynecological Care, Six Clinical Campuses of Michigan State University College of Human Medicine, 1999–2000

Medical students' participation in care

We asked patients to rate the likelihood based on a five-point scale that they would allow a medical student to participate in their health care during their ob–gyn office visit (1 = very unlikely, 5 = very likely). The likelihood of a patient allowing a medical student to participate changed depending on the source of the request. The mean rating was 3.1 if the request came from a medical assistant or aide. The likelihood of participation increased (F = 316.30, df = 2, 892, p < .001) if the request came from a nurse (3.4) or physician (3.9).

When asked about allowing a medical student to participate in their care, 676 patients (68%) reported that they would allow either male or female students to do so. One hundred sixty-two (16%) indicated that only female students could take part in their care while 141 (14%) indicated that they would not allow any medical student participation. Only 10 (1%) indicated a specific preference for male medical students.

Both patients and physicians were asked to indicate the extent to which medical students should be allowed to participate in health care delivery (see Table 3). We found a significant difference between physicians' and patients' responses (χ2 = 36.00; df = 3; p < .001). Forty-three physicians (63%) indicated that students should participate in all aspects of the health care visit, including history, physical and pelvic exam, while 299 (31%) patients reported a similar view. Two hundred fifty-eight patients (26%) and 17 physicians (25%) thought that medical students should only observe the physician. There were no differences in the ratings of male and female physicians.

Table 3
Table 3:
Patients' and Physicians' Opinions About Medical Students' Involvement in Obstetrical and Gynecological Care, Six Clinical Campuses of Michigan State University College of Human Medicine, 1999–2000

Influence of medical students' presence on choice of physician

We asked patients to consider a scenario in which they were going to choose an ob–gyn in the future and how knowing that a medical student would participate in their care would influence that choice. They were given the scenario twice, once with a female student and once with a male student. Physicians were asked a similar question about the likely influence of a medical student being present on patients' choices (see Table 4). We found no difference in the ratings of physicians and patients related to the presence of female medical students (χ2 = 4.58; df = 2; p = .10) or the presence of male medical students (χ2 = 3.09; df = 2; p = .21). However, male medical students were more likely to be associated with a negative impact than were female medical students for both patients [237 (24%) versus 86 (9%)] and physicians [24 (33%) versus 5 (7%)].

Table 4
Table 4:
Patients' and Physicians' Ratings of the Influence of Medical Students' Involvement in Obstetrical and Gynecological Care on Physician Choice, by Student's Gender, Six Clinical Campuses of Michigan State University College of Human Medicine, 1999–2000

We compared the perceived impact of medical students by the physician's gender and found no differences in the ratings of male and female physicians related to the impact of female medical students (χ2 = 1.12, df = 2, p = .57). When considering the impact of male medical students, 34 male physicians (72%) indicated there would be no impact on patients' choice and only 12 (25%) thought there would be a negative impact. In contrast, 11 (46%) female physicians thought there would be no impact and 12 (50%) thought there would be a negative impact on patients' choice of physician. These differences were not statistically significant (χ2 = 4.81, df = 2, p = .09). However, the results suggest that male physicians' ratings had a greater concordance with patients' ratings than the ratings from female physicians.

The role of prior experience with medical students

We compared the responses of patients reporting prior experience with medical students to patients without prior experience (see Table 5). The overall pattern of responses suggests that patients with prior experience were more likely to be receptive to requests to allow medical students to participate in their care, and were more likely to permit a greater level of participation.

Table 5
Table 5:
Patients' Perceptions of Medical Students' Involvement in Obstetrical and Gynecological Care Based on Prior Experience with Medical Students, Six Clinical Campuses of Michigan State University College of Human Medicine, 1999–2000

When patients were asked to consider a scenario where they were going to choose an ob–gyn in the future, knowledge of the medical student's gender had an impact on patients' ratings. We found no difference in patients' perceptions when the student was female, regardless of whether the patients had had prior experience with medical students. However when the medical student was identified as male, there was a difference in patients' responses based on their prior experience. Patients without prior experience with medical students were less likely to choose a physician with male students present than were patients with prior experience.

Predicting patients' choices

We used patients' responses to develop three multivariate regression prediction models. Three different outcomes were transformed into dichotomous variables and used in the models. Gender was the first outcome variable, comparing patients who would allow both male and female medical students to participate in their care to those who would allow only female students or no medical students. Physical Exam was the second outcome and was based on level of medical students' involvement. Patients who would permit a student to participate in a physical examination (with or without a pelvic examination) were compared to patients preferring observation or history-taking only. Male Student Impact was the third outcome, and compared patients who would be less likely to choose a physician because of the presence of a male student to those for whom it would have no impact.

The predictors in the multivariate regression analyses included age as a continuous variable, as well as the following dichotomous variables: prior experience with medical students, white, traditional insurance coverage, government insurance coverage, managed care coverage, married, and college education. In addition, we used a factor analysis to reduce the patient considerations listed in Table 2 to a smaller number of scaled items. We used a varimax rotation and a three-factor solution emerged representing medical student's attributes (Cronbach's alpha = .91), medical student's gender (Cronbach's alpha = .83) and patient's needs (Cronbach's alpha = .57) (see Table 2).

The results of the three full-model regression analyses are presented in Table 6. Beta weights are presented indicating the relative contributions of each independent variable in the prediction model. The first model compared patients who would allow both male and female medical students to participate in their care to patients who would allow only female students or no students in their care. Patients who were older, white, and those with prior experience with medical students were more likely allow both male and female students, while patients for whom the medical student's gender was an important consideration or patients whose own needs were most important were less likely to allow students of both genders. In the second model, when considering the likelihood of patients' allowing medical students to take part in their physical exam, prior experience increased the likelihood of agreement while patients' need for privacy decreased the likelihood of medical students' involvement in the physical exam. In the third model assessing the impact of a male medical student on patients' choice of a physician, prior experience and age predicted no impact. Conversely, the importance patients placed on the student's gender or their own health care needs was likely to decrease their likelihood of choosing a physician with a male medical student present. Across the three models, prior experience and age were associated with increased medical student involvement. Patients with specific needs or for whom gender was an important issue were less receptive to medical students' involvement.

Table 6
Table 6:
Beta Coefficients of Patients' Characteristics and Perceptions Predicting Patients' Attitudes Toward Medical Students' Involvement in Obstetrical and Gynecological Care, Six Clinical Campuses of Michigan State University College of Human Medicine, 1999–2000

Discussion

This study involved a large-scale survey of women regarding their views on the involvement of medical students during office visits with their obstetricians and gynecologists. In addition, their providers were surveyed to ascertain their understanding of their patients' perspectives related to medical students' involvement. Ob–gyn clinics are settings likely to elicit patients' preferences related to medical students' involvement in their care because of the intimacy of the clinical exams in these settings. Consistent with previous studies, a majority of women in our study would allow medical students to take part in their care.3,6,7,9–11,15 The likelihood of patients agreeing to medical students' involvement was greatest when the request came from the physician, underscoring the unique nature of the physician–patient relationship and the trust patients have in their providers. Alternatively, this finding may reflect the greater social influence that physicians have over patients during a clinical encounter. Patients were more concerned about the communication skills and appearance of the medical student than their own need for privacy. It has been suggested that women balance their personal needs with a feeling of responsibility to contribute to the education of physicians-in-training when making their decisions about medical students' participation.9 The prediction models provide support for this hypothesis, balancing patients' prior experience with medical students with their own needs during the visit. A limitation of our study was the patient sampling strategy. We do not know the extent to which patient recruitment and participation resulted in a biased sample.

We found that medical students' gender and level of participation moderated patients' decisions about allowing medical students to participate in their care. Generally medical students' gender was the least important factor rated by the participants in this survey, and while most patients did not express a specific gender preference, among those who did, female medical students were preferred over male medical students. This is consistent with gender bias reported in other studies.3,4,6,7,10 The involvement of medical students in the physical examination, particularly the pelvic exam, was an influential negative factor for many women.4,7,10 In contrast, most physicians felt that medical students should be allowed to participate fully in the history and physical examination. This difference underscores the importance of establishing clear and consistent expectations for the patient, medical student, and physician in each medical encounter.

Our study illustrates the impact of patients' prior experiences with medical students. While our results are consistent with those of other published reports,4,6,7,9,14 our patient sample was balanced in terms of prior experience: only half of the patients responding to the survey had had prior experience with a medical student. Prior experience with medical students was a positive predictor of patients' participation in medical education for all three prediction models. Those patients with prior experience were more receptive to medical students' presence and higher levels of participation; they also were less influenced by the gender of the student.

That patients are motivated to participate in medical education has been demonstrated by studies showing that a majority of patients, including those who have had negative past experiences with medical students, generally support medical students' participation and, in fact, see benefits to it.4 The importance of training opportunities involving real patients is self-evident. There are a variety of personal, provider, and contextual factors that influence a patient's decision to participate in medical education. There is some evidence suggesting that physicians themselves might be a source of bias related to the opportunities provided to male and female medical students. When we compared physicians' and patients' ratings, we found that physicians overestimated the importance placed by patients on the medical student's gender and the patient's need for privacy. Similarly, when we asked physicians about the appropriate level of medical students' involvement during a clinical encounter, we found their responses were comparable to those of patients; one in four physicians indicated that medical students should only observe the physician. While we found no significant differences between male and female physicians' understanding of patients' experiences and expectations, there is some indication that patient-provider gender concordance—and perhaps disconcordance—can affect the acceptability of medical students' participation in the clinical encounter. Both students and faculty need to be aware of gender-based expectations and how these can influence their professional roles and their interactions with patients.16 Obstetricians and gynecologists typically have been found to be more sensitive to these issues than other primary care providers.17,18 To the extent that patients' gender biases related to medical students are physician-driven,17 they can limit patients' access to care as well as medical students' access to valuable training opportunities.

In practice, it seems that the request to patients to allow a medical student to participate in their care is often left up to the nurse, medical assistant, or to chance. In some cases, the physician asks for patients' consent when the medical student is already in the room. This cavalier approach is not respectful of patients. Our survey results suggest that simply having a physician, rather than other office staff, ask a patient about participating in the education of a medical student as part of an office visit increases the likelihood of consent. Clearly other office personnel can play a role in patients' receptiveness to the participation of a medical student.15

The seven considerations most highly rated by patients when deciding whether to allow a medical student to participate in their care are attributes and behaviors largely under the control of students. These top-rated items clearly emphasize the importance of communication skills for building a comfortable patient-physician relationship. These attributes are likely to be consistent with the professional standards and competency expectations already implemented in many ob–gyn clerkships. Reinforcing their importance to students from a patient's perspective can be a strategic part of the orientation process; monitoring these professional standards can play an important role in student assessment.

There are other strategies for increasing patients' receptiveness to medical students' involvement. Prior studies have found evidence that some patients are not clear about the meaning of the designation “medical student” in terms of students' prior training, role within the health care setting, or even future career path.6,8,9 Knowing that many patients have altruistic motivations for participating in the education of future professionals, and providing them with clear information about the role and training level of medical students can help patients make an informed decision. Explicit processes are needed for obtaining patients' consent for medical students' involvement. Problems have been documented in implementing viable consent procedures19 and there is evidence of eroding attitudes among medical students during their clinical training about the importance of patient consent.20 Conversely, patients have been more receptive to participating in educational experiences and were more satisfied with their visit when presented with information about medical students' involvement in their clinical encounter.8,10,21

Acknowledgments

This study was funded by a grant to Madeline Colavito Dodson (now Madeline Colavito Jeffs) from the Association of Professors of Gynecology and Obstetrics Foundation.

References

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